Second Injury Questionnaire
The following questionnaire should only be completed by individuals that have been hired for employment. Your employer may ask that you complete this questionnaire following your initial hire and periodically thereafter. The questionnaire may be used in the establishment of prior knowledge for the purpose of obtaining Second Injury Fund Relief from the Second Injury Board. The Second Injury Board may reimburse your employer for workers' compensation claims that meet criteria should you become injured on the job. This reimbursement in no way affects the benefits owed to you by your employer or their insurance company under the Louisiana Workers' Compensation Act, La. R.S. 23:1021-1361.
FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORGEITURE OF YOUR WORKERS COMPENSATION BENEFITS UNDER LA R.S. 23:1208.1.
EMPLOYER:
EMPLOYEE NAME:
*
First Name
Last Name
DATE OF BIRTH:
*
-
Month
-
Day
Year
Date
SEX:
*
MALE
FEMALE
SOCIAL SECURITY NUMBER:
*
LAST 4 DIGITS
HOME ADDRESS:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
PHONE NUMBER:
*
-
Area Code
Phone Number
Personal Email address:
*
example@example.com
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Next
Please place a check in the appropriate box next to each medical condition listed below. Each illness or condition requires a YES (Y) or a NO (N) answer. For all conditions that you check yes, write a brief explanation on the Explanation Page.
Disease and Other Medical Condition:
Diabetes
*
Y
N
Silicosis
*
Y
N
Vericose Veins
*
Y
N
Asbestosis
*
Y
N
Hyperinsulinism
*
Y
N
Alzheimer's
*
Y
N
Emphysema
*
Y
N
Hearing Loss
*
Y
N
COPD
*
Y
N
Hypertension
*
Y
N
Head Injury
*
Y
N
Epilepsy
*
Y
N
Stroke
*
Y
N
Cerbral Palsy
*
Y
N
Tuberculosis
*
Y
N
Multiple Sclerosis
*
Y
N
Post Traumatic Stress
*
Y
N
Osteomyelitis
*
Y
N
Nervous Disorder
*
Y
N
Muscular Dystropy
*
Y
N
Migraine Headaches
*
Y
N
Mental Retardation
*
Y
N
Kidney Disorder
*
Y
N
Loss of Use of Limb
*
Y
N
Seizure Disorder
*
Y
N
Sickle Cell Disease
*
Y
N
Arthritis
*
Y
N
Parkinson's
*
Y
N
Brain Damage
*
Y
N
Asthma
*
Y
N
Dementia
*
Y
N
Thrombophlebitis
*
Y
N
Arteriosclerosis
*
Y
N
Hodgkin's
*
Y
N
Cancer
*
Y
N
Double Vision
*
Y
N
Mental Disorder
*
Y
N
Hemophilia
*
Y
N
Bleeding Disorder
*
Y
N
CHF
*
Y
N
Vision Loss, One or Both eyes
*
Y
N
Heart Disease/Heart Attack
*
Y
N
Disability from Polio
*
Y
N
Psychoneurotic Disability
*
Y
N
Ruptured or Herniated Disc
*
Y
N
Ankylosis or Joint Stiffness
*
Y
N
High / Low Blood pressure
*
Y
N
Carpal Tunnel Syndrome
*
Y
N
Compressed Air Sequelae
*
Y
N
Disease of the Lung
*
Y
N
Coronary Artery Disease
*
Y
N
Heavy Metal Poisoning
*
Y
N
Surgical Treatment:
Spinal Disc
*
Y
N
Approximate Date of Procedure
-
Month
-
Day
Year
Date
Spinal Fusion
*
Y
N
Approximate Date of Procedure
-
Month
-
Day
Year
Date
Amputated Foot
*
Y
N
Location
Left
Right
N/A
Approximate Date of Procedure
-
Month
-
Day
Year
Date
Amputated Leg
*
Y
N
Location
Left
Right
N/A
Approximate Date of Procedure
-
Month
-
Day
Year
Date
Amputated Arm
*
Y
N
Location
Left
Right
N/A
Approximate Date of Procedure
-
Month
-
Day
Year
Date
Amputated Hand
*
Y
N
Location
Left
Right
N/A
Approximate Date of Procedure
-
Month
-
Day
Year
Date
Knee Replacement
*
Y
N
Location
Left
Right
N/A
Approximate Date of Procedure
-
Month
-
Day
Year
Date
Hip Replacement
*
Y
N
Location
Left
Right
N/A
Approximate Date of Procedure
-
Month
-
Day
Year
Date
Other Joint Replacement
*
Y
N
Joint...
name of joint replaced
Location
Left
Right
N/A
Approximate Date of Procedure
-
Month
-
Day
Year
Date
Other Surgical Procedures
*
Y
N
Procedure Type
Approximate Date of Procedure
-
Month
-
Day
Year
Date
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Next
EXPLANATION PAGE
Please use the space below to explain the illness and/or condition that you checked a Yes (Y) or any other medical conditions that may not be listed on this form.
Condition 1:
*
Approx Date Diagnosed with condition:
-
Month
-
Day
Year
Date
Are you still treating this condition?
*
YES
NO
N/A
Are you taking medications for this condition?
*
YES
NO
N/A
Do you have any permanent restrictions for this condition?
*
YES
NO
N/A
Brief Explanation for this condition:
*
Condition 2:
*
Approx Date Diagnosed:
-
Month
-
Day
Year
Date
Are you still treating this condition?
*
YES
NO
N/A
Are you taking medications for this condition?
*
YES
NO
N/A
Do you have any permanent restrictions for this condition?
*
YES
NO
N/A
Brief Explanation for this condition:
*
Condition 3:
*
Approx Date Diagnosed:
-
Month
-
Day
Year
Date
Are you still treating this condition?
*
YES
NO
N/A
Are you taking medications for this condition?
*
YES
NO
N/A
Do you have any permanent restrictions for this condition?
*
YES
NO
N/A
Brief Explanation for this condition:
*
Condition 4:
*
Approx Date Diagnosed:
-
Month
-
Day
Year
Date
Are you still treating this condition?
*
YES
NO
N/A
Are you taking medications for this condition?
*
YES
NO
N/A
Do you have any permanent restrictions for this condition?
*
YES
NO
N/A
Brief Explanation for this condition:
*
Back
Next
Please answer the following questions:
Has any doctor ever restricted your activities?
*
YES
NO
If YES, please list restrictions
Were the restrictions permanent or temporary?
*
permanent
temporary
n/a
Are you currently restricted?
*
YES
NO
N/A
What is the medical condition for which you are restricted?
*
Are you presently treating with a doctor, chiropractor, psychiatrist, psychologist or other healthcare provider?
*
YES
NO
Please list the medical condition being treated:
Doctor's Name
Doctor's Specialty
Doctor's Office Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
If you are presently taking prescription medication other than those listed on the Explanation page, please list the medication and prescribing doctor below:
Medication and Prescribing Doctor
Have you ever had an on the job accident?
YES
NO
If you answered YES, please provide the date for each injury and the nature of the injury
How long were you on compensation?
Name of Employer
Employer's Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Has a doctor ever recommended a surgical procedure, which has not been completed prior to this date, including but not limited to knee, hip, or shoulder replacement?
YES
NO
If you answered YES, please provide the recommended surgery
Approximate date of recommended surgery?
Doctor/Surgeon's Name
Doctor/Surgeon's Specialty:
Doctor/Surgeon's Office Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Back
Next
EMPLOYEE SIGNATURE:
*
Clear
TODAY'S DATE
-
Month
-
Day
Year
Date
EMPLOYEE PRINTED NAME
*
First Name
Last Name
Submit
Should be Empty: